Performing Percutaneous Dilational Tracheostomy without using Fiberoptic Bronchoscope

Background: Percutaneous tracheostomy is an elective method that is increasingly being taken up in the intensive care unit alongside the patient’s bed. In many centers, bronchoscopy is used, but the necessity of using bronchoscopy in percutaneous tracheostomy has not yet been determined. Discontinuing use of bronchoscopy can potentially reduce the cost and increase the efficiency of percutaneous tracheostomy. Therefore, in this study, we performed a percutaneous dilatational tracheostomy without using fiberoptic bronchoscopy. Materials and Methods: This study was performed as a descriptive epidemiological survey among 70 patients in Shahid Rajaei Hospital of Qazvin in 2015 and 2016. The results were assessed in the patients. Results: In this study, pneumothorax, trauma, major and minor bleeding, cuff leak and change to surgical procedures as well as accidental extubation were not seen. However, subcutaneous emphysema, mal-position and hypoxia each were seen in one patient (1.4%). Conclusion: Totally the results demonstrated that percutaneous dilatation tracheostomy without fiberoptic bronchoscopic guidance is useful and safe.

Dilational Tracheostomy (PDT) and Surgical Tracheostomy (3,4). Although PDT method is faster and easier, it needs to be converted to open surgery in 7 percent of cases (3).
The physician experience should not be neglected that clearly reduces complications of either method (5). Yaghoubi S,et al. 61 Tanaffos 2020; 19 (1): [60][61][62][63][64][65] Although other factors like, age, gender, and history of previous intubation, have no effect on incidence of complications or successful PDT placement (6), differences in surgical methods and dealing with the anatomical problems can have a significant impact on PDT outcomes and reduction of its complications (3,4).

TANAFFOS
In old traditional way, patient was transferred from intensive care unit (ICU) to operating room, and presence of surgery team performed the tracheostomy (7). In percutaneous tracheostomy method, surgery is done by ICU physician beside the patient's bed with no need for operating room. In this way there will be less tissue damage, bleeding risk and infection due to limited tissue incision (5). Also bronchoscopy is not obligatory in performing PDT (6,8). Recent studies in trauma patients showed that using bronchoscopy does not change complications of tracheostomy (9). There is no consensus about using bronchoscope during PDT as routine or in special conditions, and in some centers bronchoscopy is never used during PDT (6,10). Whereas some studies recommend using bronchoscope as a guide during PDT, and mention that its usage, reduces complications like pneumothorax, and tracheal posterior wall damage, and is useful to treat intrabronchial hemorrhage (9). Using bronchoscope increases the safety of PDT procedure, but can cause hypoventilation, hypercarbia, and respiratory acidosis. Also, it increases the cost of percutaneous tracheostomy and will necessitate the presence of another specialist because of the complexity of the procedure (11,12). Therefore, in this study we decided to evaluate the complications of PDT without using bronchoscope.

MATERIALS AND METHODS
This study was done as a descriptive epidemiological precisely, by marking the region 2 to 3 centimeters above sternal notch between cricoid and sternal notch, and to reduce bleeding, 60 mg lidocaine with 1/10000 epinephrine was injected subcutaneously at the specified region. Then a 1.5 cm horizontal incision was given by scalpel, and pretracheal muscles were exposed. With accurate palpation of thyroid cartilage, tracheal rings were revealed, and between 2nd and 3rd midline cartilage (connected to a 10 cc syringe prefilled with 2 cc of distilled water) trachea was entered with a 14 gauge needle. Correct insertion of needle was confirmed by aspirating air. Then the syringe was removed and metal catheter was passed through the needle and inserted into trachea for about 10 cm, and free movement of guide wire inward or outward was checked. Thereafter, the needle was withdrawn and a 14-french plastic dilator was passed over the guide wire. nasotracheal tube was removed, and tracheostomy tube fixed by special banding. Portable Chest x-ray was obtained from all patients, one hour after procedure.
Amount of blood loss during procedure, SPO2 level below 90%, accidental extubation, tracheal tube cuff rupture and posterior tracheal wall rupture were recorded. Patients were followed up for incidence of pneumothorax, subcutaneous emphysema, incorrect positioning of tracheostomy tube and also tracheostomy associated death up to 24 hours after procedure.

RESULTS
In this study, 70 ICU patients underwent PDT surgery, and were monitored for incidence of complications. The descriptive results are presented in this segment.   (15). In another retrospective study in 2013 in trauma patients, it was concluded that fiberoptic bronchoscope is a very reliable method even in obese patients, but its routine use is not recommended (13).
Some studies recommend using fiberoptic bronchoscope as a guide during PDT and mention that it reduces complications like pneumothorax and posterior tracheal wall injury, and is useful to treat complications like intra bronchial hemorrhage (9).
There was no case of accidental extubation in our study. In a study which was done on 300 patients who were candidate for PDT without bronchoscopic guide, 6 (2%) accidental extubation, and 12 (4%) tracheal tube cuff rupture was reported, which happened in first 6 months of study and mostly because of assistant inexperience (16). Although PDT is a safe procedure (23), in some studies it is mentioned that duration of PDT with bronchoscopy is significantly increased, and is variable from 9 to 21 minutes according to the specialist's experience (12). The time range in this study was between 5 to 7 minutes. In a retrospective study on 300 patients who were candidate for PDT without bronchoscopy, incidence of hypoxemia was zero (16).
Considering chest x-ray findings and widespread atelectasis in the patient, decreased respiratory reserve, is probably the cause of hypoxemia.